research potential of electronic dental records · 6/17/2018  · unrestricted travel support to...

Research Potential of Electronic Dental Records

Heiko Spallek, PhD, DMD, MSBA, University of Sydney Mark Genuis, PhD, ICE Health SystemsLynn Johnson, PhD, University of MichiganJulian Fisher, PhD, DMD, Hannover Medical School

Introductions

• Mark Genuis, PhD, ICE Health Systems• Lynn Johnson, PhD, University of Michigan• Julian Fisher, MIH, DMD, Hannover Medical School• Heiko Spallek, PhD, DMD, MSBA, University of Sydney

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Lynn● U-M sponsoring institution with Internet2● No financial compensation● COI/COC filed with U-M

Heiko● No financial compensation● Unrestricted travel support to attend ADEA/AADR/IADR meetings in

2017 and 2018● Outside Earnings Declaration filed with USyd

Mark● President and CEO of ICE Health Systems

Julian● No financial compensation● Unrestricted travel support to attend ADEA/AADR/IADR meetings in

2016, 2017 and 2018● Outside Earnings Declaration filed with Hannover University

Disclosures

Agenda

● Introduction — Who is in the audience? (Heiko)● Demo — An EHR that Supports Research (Mark)● Collaboration — EHR Design by Committee? (Lynn)● Research — What data to collect? (Heiko)● Health Policy — Shifting from EDR to EHR - what

does this mean for research? (Julian)● Q/A

Demonstration

Supporting Research via Records

• Enable broad range of data into the system– All data must be organized for access

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Supporting Research via Records

• Enable broad range of data into the system– All data must be organized for access

• Support data standards (structure data)– and easy sharing of standards across the global community

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Supporting Research via Records

• Enable broad range of data into the system– All data must be organized for access

• Support data standards (structure data)– and easy sharing of standards across the global community

• Support global standards for critical elements (e.g., diagnostic and treatment terminology/codes)

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Supporting Research via Records

• Enable broad range of data into the system– All data must be organized for access

• Support data standards (structure data)– and easy sharing of standards across the global community

• Support global standards for critical elements (e.g., diagnostic and treatment terminology/codes)

• Easy and rapid (real-time) access to data– clinicians, researchers and policymakers can interrogate data

in real time

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Supporting Research via Records

• Enable broad range of data into the system– All data must be organized for access

• Support data standards (structure data)– and easy sharing of standards across the global community

• Support global standards for critical elements (e.g., diagnostic and treatment terminology/codes)

• Easy and rapid (real-time) access to data– clinicians, researchers and policymakers can interrogate data

in real time• Building block for a Learning Health System

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Product Structure

Practice Dashboard

Provider Dashboard & Educational

Patient Chart & Record (Dashboard)

Professional CollaborationsPatient Portal

Health Policy Systems Research

Content Sharing

Practice Dashboard

Provider Dashboard & Educational

Patient Chart & Record (Dashboard)

Professional CollaborationsPatient Portal

Practice Dashboard

Provider Dashboard & Educational

Patient Chart & Record (Dashboard)

Professional CollaborationsPatient Portal

Practice Dashboard

Provider Dashboard & Educational

Patient Chart & Record (Dashboard)

Professional CollaborationsPatient Portal

Practice Dashboard

Provider Dashboard & Educational

Patient Chart & Record (Dashboard)

Professional CollaborationsPatient Portal

Secure Content Sharing (reports, insurance plans, forms, note templates…)

Collaboration for Health IT:

Health Record Design by Committee

Why a Collaboration?

• EHR is foundational tool to improve personal & population health.

• Vision of researchers drives software development.• Continually refine and expand a system to support

education, research and patient care in healthcare.

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Current Collaborators

Governance through Working Groups; Work Accomplished

Governance through Working Groups; Current Work

• Efficient clinical experiences• Support learning• Excellence in collaboration & communication• Foremost software engineering practices• Exceed security regulations• Standards to support research• Dynamic data access/Business Intelligence• Robust interoperability

Founding Principles

Exceed Security Regulations

Exceed Security Regulations

Standards

Dynamic Data Access/Business Intelligence

Robust Interoperability

Glick Medical Support System

Research Vision

Atul Gawande on the potential of information for health

kinds of information that matter to your health and well-being over time, information about the state of ...• your internal systems, e.g. imaging, lab-test results• your living conditions / social determinants, e.g. housing, environment• the care you receive, e.g. medications, treatments• your behaviors, e.g. sleep, exercise

“The potential of this information is so enormous it is almost scary.” Atul Gawande: The Heroism of Incremental Care, The New Yorker, 2017,

http://www.newyorker.com/magazine/2017/01/23/the-heroism-of-incremental-care

What data can we collect?

Classes of data1. structured in traditional databases2. unstructured, e.g. images, video, voice, GIS3. Internet of Things (IoT)

https://www.apple.com/researchkit/

https://www.apple.com/healthcare/

Internet of Medical Things (IoMT)

3rd generation AliveCor Heart Monitor http://www.alivecor.com/home

Internet of Dental Things

Kolibree: http://www.kolibree.com/en/

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Traditional EHRsWhat EHRs Do Right • Billing• Legibility• Availability• Result reporting• Order entry• Alerts and reminders

What EHRs Do Wrong• Alerts and reminders (alert fatigue)• Data entry (tedious, redundant)• Incompleteness• Data overload (note bloat)• Poor navigability

Dental Records:WORN—write once read never

Unmet information• timely access to information on various subjects• better visual representations of dental problems• access to patient-specific evidence-based information• accurate, complete and consistent documentation of patient records

Data can …Guide the scientific decision-making process for

– public health officials– Other sectors (to address SDH) – Public oral health service – private practitioners

– support clinicians who want to see the whole human being– help us to focus on health outcomes and understand

differential consequences– inform consumers about choices

Current Barriers …Smartphone can do MANY things. EHR can do FEW things (= mostly a billing diary).

– Lack of interoperable systems. – EHRs’ lack of flexibility, e.g. mobile access in disaster situation.– Tapping on a plastic-covered keyboard with gloved hands…

“building a value-enabling Health IT ecosystem—largely not knowledge barriers, but execution barriers”

Adler-Milstein, Embi, Blackford Middleton, Sarkar, Smith: Crossing the health IT chasm: considerations and policy recommendations to overcome current challenges and enable value-based care, JAMIA doi:

10.1093/jamia/ocx017

"ensuring that electronic repositories become valuable resources rather than expensive investments that are quickly ignored”

Van Knippenberg, D., Dahlander, L., Haas, M., & George, G. (2015). Information, Attention, and Decision Making. Academy of Management Journal, 58(3), 649–657.

Informatics Tools"Medical thinking has become vastly more complex, mirroring changes in our patients, our health care

system, and medical science. The complexity of medicine now exceeds the capacity of the human mind.” Obermeyer, Z., & Lee, T. H. (2017). Lost in Thought — The Limits of the Human Mind and the Future of Medicine. New

England Journal of Medicine, 377(13), 1209–1211. http://doi.org/10.1056/NEJMp1705348

- analytics tools ranging, e.g. machine learning, deep learning, neural networks, etc.

- aggregation of data in cloud-based storage systems

- standardization, reduction of customization

- permit patients access to their data in a computable format*

- improve interoperability in a context of Application Programming Interfaces (APIs)*

- simplify clinical documentation for reimbursement and quality measurement*

- more readily engage patients in research*

- foster an ecosystem of safe, effective and secure health applications*

*Adler-Milstein, Embi, Blackford Middleton, Sarkar, Smith: Crossing the health IT chasm: considerations and policy recommendations to overcome current challenges and enable value-based care, JAMIA doi: 10.1093/jamia/ocx017

What can be done with Big Data?

Mayo Clinic (59,000 employees) + UnitedHealth Group ($122 billion corporation) + Optum Labs :

$300m res earch s tudy over 5 years : repeated in hours , s ame res ult

https://www.optum.com/optumlabs/research-principles.html

Data Availability in Clinical Setting

Four perspectives

• Patient: Provision of tools/ data to engage patients and make them part of the decision making process about their care

• Clinicians: Provision of all relevant data to allow clinicians to make the right decisions about patient care and reflect on their practice

• Services: to use data to support system efficiency and resource allocation as well as improve safety and quality

• Policy Makers: Access to data to make decisions regarding value of care and safety and quality, e.g. “oversight” of data such as trends that emerge when connecting various data sources

Learning Health System (LHS)Health systems--at any level of scale--become learning systems when they can, continuously and routinely, study and improve themselves

Perspective: Jan 3, 2013“C ode R ed and B lue — S afely Limiting Health C are’s G DP Footprint”

Arnold Mils tein, M.D., M.P .H.

…U.S. health care needs to adopt new work methods, outlined in the Institute of Medicine’s vision for a learning health system…

Electronic Medical Record (EMR) Electronic Dental Record (EDR)

Integration for • safe and efficient patient care, e.g. allergies, medication• health profession education based on interprofessional education principles• biomedical research that acknowledges that the mouth is part of the body

If you want to bring healthy lives and healthy mouths together, you also need to bring EMRs and EDRs together!

Sample research questions- Is maintaining a full dentition important for older patient?- Does pre-chemo dental therapy help? - What role does the dentition play in dialysis outcomes? - Does a healthy dentition improve overall health?

How can we accelerate 17 years to 17 months

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A Health System That Can Learn

• Every patient’s characteristics and experience are available for study

• Best practice knowledge is immediately available to support decisions

• Improvement is continuous through ongoing study

• This happens routinely, economically and almost invisibly

• All of this is part of the cultureCharles P. Friedman, PhD

Josiah Macy, Jr. Professor of Medical EducationChair, Department of Learning Health Sciences

Professor of Information and Public HealthUniversity of Michigan

Data FAIRness & Knowledge FAIRness

• Deliberate and evolutionary process of infrastructure co-production in which the full spectrum of stakeholders are directly engaged.

• Purposefully collected data outside of care experience can be important components of the learning process.

Friedman, Rubin, Sullivan: Toward an Information Infrastructure for Global Health Improvement, IMIA May 2017: https://imia.schattauer.de/en/contents/archive/issue/special/manuscript/27496.html

What would an EHR system look like that dentists suddenly can’t live without?Paraphrased from:

When lead engineer of I.B .M.’s Wats on’s health team, E ric B rown, was as ked what the equivalent of the “J eopardy!” victory would be in medicine, he res ponded:“It’ ll be when we have a technology that phys icians s uddenly can’t live without,”http://www.nytimes .com/2015/03/22/opinion/sunday/why-health-care-tech-is -still-so-bad.html? _r=0

Future EHR

Policy

Shift from EDR to EHR

Symbolic of trend EDR to EHR; mouth into body eg SDG 3 and NCDs

Catalysts and drivers for change: JF to give brief summary and examples ● Health service● Health workforce education● Reframing SDG 2030 agenda where is OH?

What does this mean for OH research?

Allows us measure and understand the problem from a systems perspective - to collect and analyse oral health data at 3 levels: clinical, community and national policy in coherent and consistent manner

More effectively identify population health needs to guide national health plans that integrates oral health as part of dynamic ‘real time’ process with other health professions and other sectors

Eg Dental caries evidence on sugar guided WHO guidelines which are normative basis for national health policy

Eg NCD real time data of risk factors from the chairside and extended oral health workforce

Oral health workforce education

EHR at 3 levels will support shift to health education systems (lancet report / UN Commission)

Population health needs will guide HWF competencies and will:

Assist aligning health worker competencies and performance, as well as organizational capacity and capabilities

Build and strengthen the evidence base for socially accountable transformative education and necessary reforms

Assist with development of accreditation standards

Research Potential of Electronic Dental Records

Heiko Spallek, PhD, DMD, MSBA, University of Sydneyheiko.spallek@sydney.edu.au

Mark Genuis, PhD, ICE Health Systemsmgenuis@icehealthsystems.com

Lynn Johnson, PhD, University of Michiganlynjohns@umich.edu

Julian Fisher, PhD, DMD, Hannover Medical SchoolFisher.Julian@mh-hannover.de